1225092794 NPI number — DR. RICHARD W GRAHAM M.D.

Table of content: DR. RICHARD W GRAHAM M.D. (NPI 1225092794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225092794 NPI number — DR. RICHARD W GRAHAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
RICHARD
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225092794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANDOLPH
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05060-1381
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-728-2372
Provider Business Mailing Address Fax Number:
802-728-2613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE RIVER JUNCTION
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05001-7056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-296-7370
Provider Business Practice Location Address Fax Number:
802-296-7174
Provider Enumeration Date:
04/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  0101 033452 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 042-0012170 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1225092794 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24388 . This is a "ALLIANCE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 32000393 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59294 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2582 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 340001591 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 447989 . This is a "SOUTHERN HEALTH EFF111506" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 45722 . This is a "SENTARA FAMILY CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1900011 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 36538 . This is a "CARENET" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3762531 . This is a "AETNA HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4063408 . This is a "AETNA PPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 497602109 . This is a "TRICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 247815 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3016615 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 002130301 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1478176 . This is a "CIGNA" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1018994 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 642070000-00 . This is a "QUALCHOICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 66241 . This is a "CARENET EFF 111506" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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